Impact of home NIV on severe exacerbations and survival in COPD: a French nationwide cohort study using multistate models

<bold>Background:</bold> COPD is the most common indication for home NIV but long-term outcomes data are limited. This multistate model analysis estimated the impact of NIV continuation versus cessation on transitions between three different disease states (without severe exacerbation, severe exacerbation, death). <bold>Methods:</bold> Model data came from a national insurance reimbursement system database for individuals with COPD aged ≥40 yrs who had ≥1 reimbursement for NIV in 2015–2019. A multistate model was used to estimate the impact of continuation vs cessation of NIV on transitions between three states of interest (without severe exacerbation, severe exacerbation, death). A multistate adjusted Cox model was used to study the association between different transitions and NIV continuation versus cessation. <bold>Findings:</bold> 49 503 incident patients with COPD started on NIV were included, age 70 [62–79] yrs, 51.2% male. 80 361 severe exacerbations and 18 125 deaths were observed. In multistate models, continuation of NIV was associated with a significant reduction in transition to death, both from severe exacerbation (HR 0.84, 95% CI (0.79–0.91) and without exacerbation (HR 0.88, 95% CI (0·83–0·93)). Continuation versus cessation of NIV had no significant effect on transition between without exacerbation to severe exacerbation (HR 0.98, 95% CI (0·95–1·00)) but was associated with slower transition from severe exacerbation to without exacerbation (HR 0.87, 95% CI (0.84–0.89)). <bold>Interpretation:</bold> home NIV reduced the risk of transitions to death, but did not speed up recovery time after a severe exacerbation. These data highlight the mortality benefits associated with home NIV.